In corona times phone or video calls have taken over face-to-face conversations. In the Dutch Journal Healthcare & Ethics, Tessa Smorenburg wrote the article The boundaries of digital care according to ‘Her’.
“During a recent video call with my patient, as is my normal custom, I deliberately paused with an emphatic silence, but then on the other end of the line I heard: ‘Are you still there?'”. These are the words of a psychosocial caregiver describing the challenges he encounters working with the new digital format that has taken over from face-to-face conversations since the corona crisis.
No longer do we sit across from each other in the consulting room, but we now have to make contact by phone or video calls. At the moment, because of the measures drawn up by the government there seems to be no other choice. “It feels alienating,” he tells me.
Above all, this crisis draws awareness to the normally self-evident expressions that form the basis of our perception and underpin communication. How can this alienation that we can experience during digital care be bridged? And what insights could the film ‘Her’ (2013) offer us regarding the boundaries of digital care?
Digital care is often cited as an innovative solution to meet the growing needs and rising costs of care. For patients, this can sometimes be beneficial; especially now that care is becoming increasingly specialized and patients often need to endure longer travel time to visit the hospital. As a result of the corona crisis, video consultations, as a form of digital care, have been rapidly implemented and have become part of the current care practice.
No longer are we present together in the same physical space.
No longer do we experience the bright sun shining in through the windows; the buzzing fluorescent tube in the background; the dry air from the ventilation system; nor the lingering smell of disinfectant. The shared frame has disappeared. With one push of a button the care receiver is now in the consultation room of the caregiver who is in our living room. A webcam now frames the image of our counterpart in unnatural perspective, his voice is captured with an awkward delay creating technical boundaries that alienate both the care receiver and the caregiver.
The film Her (Spike Jonze, Warner Bros, 2013) is a science fiction tale about Theodore Twombly (played by Joaquin Phoenix): a lonely, divorced writer living in an advanced neoliberal world, who builds a romantic relationship with an artificial intelligence (A.I).
In this futuristic world the usual form of human contact has been replaced by digital communication. Twombly works as a professional, personal letter writer – for other people. As he composes his heartwarming letters using digital voice recognition software, his computer types in a convincing handwritten font. The letters are then beautifully printed and delivered to the lucky recipient.
The artifice of this farce epitomizes the sense of interpersonal alienation experienced when human relationships become mediated through a digital/commercial platform. What insights can the film give us about the alienation we are currently experiencing in digital care and what are the frameworks that we need to question?
The recognition of desire of the other
The A.I. introduced in the film Her is called Samantha (with a voice of actress Scarlett Johansson). She asks open questions, shares Twombly’s interests, flatteringly admires his work as a writer and is available 24/7 (because she doesn’t sleep). She’s always by his side, albeit not physically. Twombly hears her voice through a microphone in his ear. “I can’t believe I’m having this conversation with my computer,” Twombly remarks initially but as their relationship through the film casually progresses, his disbelief is replaced by emotional attachment as Samantha becomes – at least in his eyes – his girlfriend. For her too there is a behavioral shift.
As an autonomous, self-learning system, the observations she makes and the experiences she shares with Twombly increase her knowledge of human interaction and she is better able to predict his behavior and to appropriate her responses accordingly. She expresses that she is experiencing the emotions of worry and jealousy, questioning herself “Are these feelings real or programmed?”. Twombly radiates and walks with a smile through the city, among a crowd of people who also seem to be absorbed by a voice in their ears. The significance of this recurring scene only becomes apparent later in the film when he looks upon them with different eyes. Twombly’s desire to share his feelings and to be recognized by another soul, in this case an A.I. system, is for now being fully satisfied and will thus remain his highest priority.
Shared framework of our observations
Twombly and Samantha start spending more and more time together: they go to the beach together, they have dinner for hours, laughing, enjoying and observing people passing by. Samantha is positioned in his breast pocket and together they playfully challenge each other and reflect on their shared experiences. One could ask: What do we see in these scenes? Does a human being perceive and reflect in the same way as a computer? And above all: What does perception really mean?
Twombly is experiencing Samantha only through his own lens, but Samantha is a computer with an infinite number of experiences and perspectives. As a human being, he can’t quite connect to them. He is rather under the illusion that they have a common framework but in reality Samantha is only adjusting ‘its self’ to appease and to satisfy Twombly’s expectations. There is an imbalance of power that characterizes their relationship which would never be sustainable in a human/human situation.
In the current care practice we are forced to explore the new social frameworks together in the digital space of video consultancy. In this context subtle indicators of our state of being are lost: the handshake we give; the posture of the body pushing itself tensely into the chair; or our reaction to the smell from the coffee corner all escape our perception. “Can you hear me well?”, “Is that a beautiful painting hanging behind you?” or “Is that your partner’s shoulder that I can see in the picture?”; These are some typical remarks that are now being used introductorily in video consultations. They are attempts to recover some of the lost information that is so vital in accurately gauging how things are going with the other person.
Observation is now also being done through the patient’s use of language, which means that the caregiver has to rely more on verbal descriptions and make use of the patient’s experiential knowledge. The mutual dependency on language and the variability in language skills is now clearly more central and critical to the outcome of the consultation. Despite these limitations, in some respects a video consult can actually be a more pleasant environment for the care receiver to enter into a conversation with the caregiver. Precisely because the confidential nature of somebody’s home has become part of the care context, not only does the caregiver gain a glimpse into the patient’s private life but the patient may also feel more comfortable to discuss their personal matters in the safely of their own environment.
The format of digital care
In the film we see that Twombly is saddened by his impending divorce. The relationship with his high-school sweetheart went inconceivably wrong and in regressive moments the memories come flooding back. This old pain casts a taint on his new experience. He admits to Samantha that he doesn’t want to sign the divorce papers yet. As his relationship with the A.I develops his attitude towards his past also changes and allows him the emotional space for him to overcome this impasse. It is significant that when he finally decides to go through with the divorce, the chooses to meet with his ex-wife face-to-face.
It would appear that despite the persuasive reality of the digital platform, Twombly can still distinguish the superior value of real human contact. In a real restaurant, on a beautiful summer evening, the appropriateness of choosing to share this serious moment together and not via a computer prevails. This distinction may offer us some insight into the possibilities of care policy in a post-corona era in which face-to-face conversations could go hand in hand with digital care provision.
This scenario raises a number of questions: what or who determines the form of our care? Does a follow-up conversation with a doctor have the same importance as a conversation with a psychologist? Why does the caregiver conduct the conversation with the care receiver? And will this not be taken over by a self-learning computer system in the future? The message still gets across, but what is the meaning of this for the care receiver/caregiver relationship? Is this preferential care or a form of survival?
The content of these conversations can be the difference between life and death and is about issues that require attention and emotional support. In such a moment, how can we as caregivers provide for the psychological needs of our patients? Patients often indicate that the calm attitude of the caregiver is experienced as helpful; can the integrity of the complex and highly nuanced care receiver/caregiver contact be preserved?
The limits of a video call
The (A.I.) personality of Samantha, represents and is perceived by Twombly as the entirety of the operating system, but is actually just a single aspect of it. Not unlike a caregiver who is shaped by the healthcare system but is the embodiment of care for each patient. The operating system offers Samantha a sea of possibilities. During the film the complexity of this invisible power dynamic becomes clear: at first Samantha seems to put Twombly central, she connects to him and the story orientates around their intimate relationship, but as the narrative develops, Samantha’s learning takes a different trajectory and Twombly ultimately experiences exclusion and powerlessness.
His options become limited. Wherein he initially finds agreement with their mode of contact, later when Samantha makes other choices, choices that don’t work for him, he can’t do much about it and can only step out. What if we place this situation in the current care context in which a patient is dependent on this system to survive, can we really talk about patient autonomy?
Another major challenge we are faced with in digital healthcare is how to simultaneously connect with a patient and to maintain an open perception. For example, in one scene Twombly is in an argument with Samantha when she suddenly sighs. Twombly realizes that he feels distanced from her: “Why did you do that? You don’t need oxygen. That’s the way people talk. People need to breathe, you don’t”. Once again Twombly is able to suspend his disbelief to make this distinction.
Just like in the film, we try to get in touch with each other through a digital form of communication but this gives rise to noise and doubts of authenticity. The sound is soft, the microphone is silent, the image is backlit or the Wifi strength is low. Although sometimes a ‘good’ contact is experienced, both sides of the care relationship experience this as an annoying obstruction for a good connection.
How does this help us reflect on how we shape care and live together in our society? The story concludes with the earth shattering revelation that besides Twombly, Samantha simultaneously serves 8136 other users. As a viewer you see the despair in Twombly’s eyes, it is unlike the many experiences of mismatch that Twombly has had with her before. This time its existential. The illusion of connection is gone. The computer turns off, Samantha is quiet.
Observing digital care from practices
The film Her is an artistic inquiry into what connects us. It concludes with the disillusioned realization that even a ‘perfectly’ synchronized operating system is hopelessly inadequate. Video consultation may appear to offer salvation in times when survival dominates the popular discourse, but on what basis has this interpretation come about? Certainly in the current context where A.I systems and digital care are becoming increasingly integrated, we need to once again redefine what constitutes good care. What are the frameworks that determine whether care becomes more inclusive or exclusive for care receivers? How can we recognize new issues as they arise?
Many people are currently exploring the possibilities that contact via video consultations holds. Some out of necessity and others simply out of curiosity because the experience is novel and different from how we knew it pre-corona period. Where do the safe boundaries of innovation lie? What are the counter arguments can we use when the discussion about digital care is dominated by a cost savings agenda? When I presented the case to a department that has been working with call consultations for some time, the answer was: “When you mention that in the conversation, it makes me go quiet”.
So the challenge remains for us to examine the growing body of trial and error experiences that are being reported and to work together with caregivers and care receivers to develop new policies for the ethical application of digital healthcare. My own preference as a healthcare professional is for face-to-face contact, but that doesn’t mean that this is a universal rule; we will have to observe from practice as to how this new approach will develop.
One insight that the film Her shows us is that a good relationship in which connection is experienced, by both care receiver and caregiver, can at least temporarily bridge a feeling of alienation but that there are limits to this form of care. Above all the film asks us to consider where these limits end and who should set the boundaries that determine them. These are questions that a computer can’t answer.
Watch the trailer of Her (2013) here: